Although the global burden of typhoid fever remains high, the global community has yet to coalesce around a comprehensive global policy or strategy for the management of the illness.
World Health Organization
In 2003, the World Health Organization (WHO) published Background Document: The Diagnosis, Treatment and Prevention of Typhoid Fever. Although this report is not intended as policy guidance, it outlines key prevention tools—including safe water, food safety, sanitation, and health education, alongside vaccines—as elements of a comprehensive prevention approach. The report identifies appropriate antibiotics as the proper course of treatment for typhoid fever, and it acknowledges antibiotic resistance as a growing issue. WHO partners with national governments during an outbreak to set forth specific guidelines to curb escalation.
In 2008, WHO published a position paper for typhoid, which acknowledged the international public health impact of the disease. Designed for national public health officials and immunization program managers, the position paper on typhoid fever and typhoid vaccines serves as the framework in which typhoid interventions are considered. The paper considers the high burden of typhoid fever and increasing drug resistance in relation to the safety, efficacy, feasibility, and affordability of two licensed vaccines (Vi and Ty21A). It states that “countries should consider the programmatic use of typhoid vaccines for controlling endemic disease.” For most countries, control efforts will focus on vaccinating high-risk groups and populations. The paper also acknowledges the epidemic potential of typhoid fever and recommends using vaccines as a method for outbreak control. Additionally, the 2008 recommendation states that “all typhoid fever vaccination programmes should be implemented in the context of other efforts to control the disease, including health education, water quality and sanitation improvements, and training of health professionals in diagnosis and treatment.”
In an updated Weekly Epidemiological Record published in 2017, WHO refers to typhoid conjugate vaccines (TCVs) but defers a recommendation until additional data are reviewed later this year.
Gavi, the Vaccine Alliance
Every five years, Gavi, the Vaccine Alliance develops the Vaccine Investment Strategy (VIS) to determine which vaccines will be available through Gavi’s support programs. In 2008, Gavi prioritized typhoid vaccines for inclusion in the portfolio. However, since licensed polysaccharide typhoid vaccines are not suitable for infants and TCVs were thought to be on the horizon, no financial commitment was made at that time.
In the most recent VIS, developed in 2013, Gavi did not reevaluate TCVs as they were already prioritized in the earlier strategy. At this time, Gavi agreed that a funding window could be opened if a suitable TCV reached prequalification status and was made available in the 2013 strategy’s time frame.
Gavi will revise the VIS again in 2018; the inclusion of TCVs is contingent upon recommendations from the Strategic Advisory Group of Experts on Immunization. In order for Gavi to consider allocating funds for TCVs, at least one prequalified product must be available.
Photo: PATH/Rocky Prajapati